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Original Investigation
Caring for the Critically Ill Patient
July 16, 2019

Effect of an ICU Diary on Posttraumatic Stress Disorder Symptoms Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial

Author Affiliations
  • 1Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, INSERM, Paris Diderot University, Department of Biostatistics - HUPNVS. - AP-HP, UFR de Médecine - Bichat University Hospital, Paris, France
  • 2Department of Biostatistics, Outcomerea, Paris, France
  • 3Medical unit, French British Hospital, Levallois-Perret, France
  • 4LPPS-EA4057, Laboratory of Psychopathology and Health Process, Paris Descartes University, Paris, France
  • 5Medical ICU, Les Oudaries Hospital, La Roche-sur-Yon, Vendée, France
  • 6Department of Intensive Care, Dieppe General Hospital, Dieppe, France
  • 7Medical-Surgical ICU, General Hospital, Melun, France
  • 8CRICS-TRIGGERSEP group, Medical-Surgical ICU, Tours University Hospital, Tours, France
  • 9Medical-Surgical ICU, Rangueil University Hospital, Toulouse, France
  • 10Medical-Surgical ICU, Hospital Robert Boulin, Libourne, France
  • 11Medical-Surgical ICU, General Hospital, La Rochelle, France
  • 12Medical ICU, University Medical Center, Rouen, France
  • 13INSERM U-1096, University of Rouen, Rouen, France
  • 14Medical ICU, Albert Michallon University Hospital, Grenoble, France
  • 15Medical ICU, La Cavale Blanche University Hospital, Brest, France
  • 16Group of medical ICUs, Lille University Hospital, Lille, France
  • 17Medical-Surgical ICU, General Hospital, Périgueux, France
  • 18Medical ICU, Edouard Herriot University Hospital, Lyon, France
  • 19Medical ICU, Nantes University Hospital, Nantes, France
  • 20EA3826, Laboratory of Clinical and Experimental Therapeutics of Infections, University of Nantes, Nantes, France
  • 21Medical ICU, Gabriel-Montpied University Hospital, Clermont Ferrand, France
  • 22LMGE UMR CNRS 6023, University of Clermont-Ferrand, Clermont Ferrand, France
  • 23Medical-Surgical ICU, General Hospital Belfort-Montbéliard, Belfort, France
  • 24Medical ICU, Beaumont General Hospital, Beaumont, France
  • 25Medical ICU, Hospices Civils de Lyon, Edouard Herriot University Hospital, Lyon, France
  • 26Medical-Surgical ICU, Great Hospital of East Francilien, Meaux, France
  • 27Surgical ICU, Lille University Hospital, Lille, France
  • 28Medical-Surgical ICU, Saint Joseph Hospital Network, Paris, France
  • 29Medical ICU, Saint Louis University Hospital, Paris, France
  • 30Medical ICU, Saint Antoine University Hospital, Paris, France
  • 31Medical-Surgical ICU, Gustave Roussy Cancer Campus, Villejuif, France
  • 32Medical Surgical ICU, University Hospital Paris -Sud, Beclère University Hospital, Clamart, France
  • 33Medical-Surgical ICU, General Hospital, Troyes, France
  • 34Medical-Surgical ICU, General Hospital Victor Dupouy, Argenteuil, France
  • 35Medical ICU, Bichat University Hospital, Paris, France
  • 36Medical ICU, François Mitterrand University Hospital, Dijon, France
  • 37Medical ICU, Cochin University Hospital, Paris Centre Hospital Group, AP-HP, Paris, France
  • 38Medical-Surgical ICU, General Hospital René Dubos, Pontoise, France
  • 39Lille University, Inserm U1190, Lille, France
  • 40Surgical ICU, Henri Mondor University Hospital, Créteil, France
  • 41Medical ICU, Raymond Poincaré University Hospital, Garches, France
  • 42Medical ICU, General Hospital Robert Ballanger, Aulnay-Sous-Bois, France
  • 43Grenoble Alpes University, INSERM, University hospital Grenoble Alpes, HP2, Grenoble, France
JAMA. 2019;322(3):229-239. doi:10.1001/jama.2019.9058
Visual Abstract.
Visual Abstract.
Keeping an ICU Diary and PTSD Symptoms in Patients Receiving Mechanical Ventilation
Keeping an ICU Diary and PTSD Symptoms in Patients Receiving Mechanical Ventilation
Key Points

Question  What is the effect of an intensive care unit (ICU) diary, filled out by family members and ICU clinicians, on posttraumatic stress disorder symptoms among patients receiving mechanical ventilation?

Findings  In this randomized clinical trial of 657 patients, significant posttraumatic stress disorder symptoms at 3 months, defined as an Impact Event Scale-Revised score greater than 22 (range, 0-88; a higher score indicates more severe symptoms), occurred in 29.9% of patients in the ICU diary group and 34.3% of patients in the control group, a difference that did not reach statistical significance.

Meaning  These findings do not support the use of ICU diaries for preventing posttraumatic stress disorder symptoms after ICU hospitalization.

Abstract

Importance  Keeping a diary for patients while they are in the intensive care unit (ICU) might reduce their posttraumatic stress disorder (PTSD) symptoms.

Objectives  To assess the effect of an ICU diary on the psychological consequences of an ICU hospitalization.

Design, Setting, and Participants  Assessor-blinded, multicenter, randomized clinical trial in 35 French ICUs from October 2015 to January 2017, with follow-up until July 2017. Among 2631 approached patients, 709 adult patients (with 1 family member each) who received mechanical ventilation within 48 hours after ICU admission for at least 2 days were eligible, 657 were randomized, and 339 were assessed 3 months after ICU discharge.

Interventions  Patients in the intervention group (n = 355) had an ICU diary filled in by clinicians and family members. Patients in the control group (n = 354) had usual ICU care without an ICU diary.

Main Outcomes and Measures  The primary outcome was significant PTSD symptoms, defined as an Impact Event Scale-Revised (IES-R) score greater than 22 (range, 0-88; a higher score indicates more severe symptoms), measured in patients 3 months after ICU discharge. Secondary outcomes, also measured at 3 months and compared between groups, included significant PTSD symptoms in family members; significant anxiety and depression symptoms in patients and family members, based on a Hospital Anxiety and Depression Scale score greater than 8 for each subscale (range, 0-42; higher scores indicate more severe symptoms; minimal clinically important difference, 2.5); and patient memories of the ICU stay, reported with the ICU memory tool.

Results  Among 657 patients who were randomized (median [interquartile range] age, 62 [51-70] years; 126 women [37.2%]), 339 (51.6%) completed the trial. At 3 months, significant PTSD symptoms were reported by 49 of 164 patients (29.9%) in the intervention group vs 60 of 175 (34.3%) in the control group (risk difference, −4% [95% CI, −15% to 6%]; P = .39). The median (interquartile range) IES-R score was 12 (5-25) in the intervention group vs 13 (6-27) in the control group (difference, −1.47 [95% CI, −1.93 to 4.87]; P = .38). There were no significant differences in any of the 6 prespecified comparative secondary outcomes.

Conclusions and Relevance  Among patients who received mechanical ventilation in the ICU, the use of an ICU diary filled in by clinicians and family members did not significantly reduce the number of patients who reported significant PTSD symptoms at 3 months. These findings do not support the use of ICU diaries for preventing PTSD symptoms.

Trial Registration  ClinicalTrials.gov Identifier: NCT02519725

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